What is the recommended treatment progression for a patient with a left posterior patella fracture?

Treatment Progression for Left Posterior Patella Fracture

Surgical fixation is recommended for posterior patella fractures with >2-3 mm articular step-off or >1-4 mm displacement, or when the extensor mechanism is disrupted, followed by early mobilization and comprehensive rehabilitation to optimize functional outcomes and prevent complications. 1

Initial Assessment and Treatment Decision

Determine Fracture Displacement and Extensor Mechanism Integrity

• Undisplaced fractures (<2-3 mm step-off, <1-4 mm displacement) with intact extensor mechanism can be treated conservatively with immobilization 1
• Displaced fractures require surgical intervention to restore articular congruity and prevent posttraumatic arthritis 1
• Examine for active knee extension against gravity—inability indicates extensor mechanism disruption requiring surgery 2
• Consider CT imaging preoperatively as it frequently changes both fracture classification and treatment planning compared to plain radiographs alone 1

Surgical Treatment Approach

Operative Fixation Techniques

• Tension band wiring remains the most commonly employed technique for transverse fractures 1
• For comminuted posterior fractures, supplementation with interfragmentary screws, cerclage wire/suture, or plate-and-screw constructs may be necessary to achieve adequate stability 2
• Anatomical reconstruction of the articular surface is mandatory to prevent posttraumatic osteoarthritis 1
• Percutaneous techniques may be considered, though evidence is very limited and of very low quality regarding superiority over open approaches 3

Common Surgical Pitfall

• Hardware removal is frequently required after fracture healing due to implant-related pain 1

Postoperative Management

Immediate Postoperative Care

• Appropriate pain management is essential throughout treatment 4
• Early mobilization should begin once fracture stability allows 5
• Monitor for complications including infection, loss of reduction, hardware complications, and extensor mechanism insufficiency 6

Rehabilitation Protocol

• Implement early physical training and muscle strengthening as soon as fracture stability permits 4, 5
• Continue long-term balance training for fall prevention 4, 5
• Close monitoring with follow-up imaging is necessary to detect loss of reduction 5

Secondary Fracture Prevention (Age ≥50 Years)

Systematic Evaluation Required

• All patients aged 50 and over require systematic evaluation for osteoporosis and subsequent fracture risk 4, 5
• Evaluation should include clinical risk factors, DXA of spine and hip, vertebral fracture imaging, and falls risk assessment 4

Non-Pharmacological Interventions

• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) 4, 5
• Counsel smoking cessation and alcohol limitation 4, 5

Pharmacological Treatment

• Consider pharmacological treatment with agents proven to reduce vertebral, non-vertebral, and hip fracture risk (alendronate, risedronate, zoledronic acid, or denosumab) 4, 5
• Monitor regularly for tolerance and adherence 4

Expected Outcomes and Long-Term Considerations

Functional Prognosis

• Patellofemoral arthrosis is very common after patella fractures regardless of treatment quality 2
• Substantial functional deficits may persist long-term including knee stiffness, loss of extension, and chronic pain 1, 6
• Patient education about disease burden, risk factors, and treatment duration is essential 4, 5

Complications Requiring Advanced Management

• Nonunion, posttraumatic arthritis, arthrofibrosis, and extensor mechanism insufficiency may require advanced reconstructive techniques 6